Capitalize headings under Physical Exam?

I really have a problem under the Physical Examination trying to figure out what goes where when the headings aren't dictated. For instance, in this dictation, she dictates lungs, describes her exam of them, then goes on to say, "Mass in the back and the left paraspinous area is measured..." Would this stay under the lungs or would I make a new heading...if so, if "Back" an acceptable heading? Next, she talks about the pelvis...would this go under a heading with a "Pelvis" labe ...

The sentence starts off with Admission which I know would be capped but what about the rest (History and Physical)? Thanks... ...

Extremities: 3+ edema. s/l kidneys bilaterally. What could "kidneys" be? ...

Cardiovascular system: Heart sounds regular. No murmurs. No gallops heard. s/l "percussed" respiratory sounds masking the heart sounds. Abdomen soft. Patient with URI symptoms. Does this make sense in this context? Thanks! ...

The dictation talks about a blood culture, then a chest x-ray, then says glucose 78 and then after that i cant tell it sounds like they say few in 8, cracken 0.4 then goes on to talk about the electrolytes, please any help will be appreciated. ...

I am typing a new doc that does not dictate the headings in his physical exam, however i am required to add them in. I am horrible sometimes at determining the headings so i am hoping to get some input on this file. A moderate hematoma persists over the proximal anterior tibial area which is somewhat fluctuant but not tender. Lumbar flexion is 60 degrees. Lumbar extension is 20 degrees. Lateral flexion is decreased to the left as compared to the right. The l ...

Dictated .... Her affect is somewhat tense, a little anxious. Speech is S/L lunar and lucid. TIA ...

I'm having trouble with one part of this physical exam... NECK: Supple. Trachea is midline. The patient has s/l "emanciation of aphasees" but no signs of skin breakdown. LUNGS: Clear to auscultation... I feel like I know what he's trying to say, but I can't put my finger on it. Thanks so much for your help! ...

The patient is afebrile. Af_____ is appropriate. Heart rate 110. any suggestions on what the blank could be? TIA ...

Under physical exam of a patient with back pain the doctor states what sounds like "pain is reproduced by flexion, extension and "side orientator side" of his back. Has anyone heard of a phrase that sounds like that? ...

Disks sharp on funduscopy. Cranial nerves 2-12 intact. No signs of appendicular s/l "cori ditosis", dysmetria, ataxia. Reflexes were 1/4 bilaterally with no asymmetries. thanks. ...

S/l he is saying "scariotristic???? changes of the skin" ...

In the derm part of this physical exam, the patient has "s/l mediastatious changes in the lower legs." This condition is not referred to anywhere else in the dictation. The patient has diabetes, OA, fibromyalgia, and she is obese. ...

Never seen or heard before. New doc states in extremities portion...No clubbing, cyanosis or edema. EDVLSWNL. At least that what is sounds like. Could possibly be EDVLSWNO but don't know what that would be either. Has anyone here heard of this? Thanks! ...

This is an ESL doctor who is a very good dictator, but for some reason this part always trips me up. She says what sounds like: "Cardiovascular: S1, S2, plus 0. No murmurs, rubs, or gallops." It's the plus 0 part that gets me. Any ideas? ...

Pt has fibromyalgia and polyarticular joint pain. ...

Physical Exam: Extremities (sounds like no tumor). What could it be? ...

I have listened to this over and over and it sounds like this doctor is saying, "No clubbing, cyanosis, edema, or lesions. Full range of motion s/l of/in both pulses." Then he goes on to the neurologic part of the exam. Can anyone help me with this, please? ...

Not sure where to put this. Just started doing nursing home dictations and I need to know where "Patient is drinking thickened liquids." would go under the PHYSICAL EXAM. I'm thinking Neuro, but not sure. ...

Has anyone ever heard: "Marxers and premarxers are negative"? This is on physical exam. Does not sound like marchers and premarchers, but definite x sound. Thanks! ...

I added all the subheadings. I am sure of the subheading Neurology and eyes. Any suggestions? Anything else look incorrect? I am still new to this. Thanks for the help. PHYSICAL EXAMINATION VITAL SIGNS: Blood pressure is 112/80, weight is 155 pounds, and height is 5 foot 6 inches. GENERAL APPEARANCE: Well-developed, well-nourished. No apparent distress. HEART: Regular rate and rhythm. No murmurs, carotids. No bruits bilaterally. NEUROLOGY: Orientation and language are normal. EYES: Fu ...

Hi, I'm a fairly new MT. I come across "patient is nontoxic" often enough and I've come to think it means he is not sick/contagious. Google searching does not yield much. Maybe I'm missing something. Report today had doctor describing patient who has a rash/contact dermatitis. He begins to say he is "nontoxic" but then seems to swallow the end as if changing his mind. My question is--Would a patient with contact dermatitis who is NOT sick in any ...

Patient developed a rash from Bactrim. Under physical exam the doc states....... SKIN: The skin shows a diffuse erythematous urticarial rash that blanches under pressure. There is no __________ sign. Blank sounds like NICKELOWSKI Thanks for any help! ...

Apprehension on patellar tracking with increased Q-angle, positive ____ and crepitus and positive grind test. s/l chase sign or just chase Thank you for any help. ...

I have transcribed: PELVIC EXAM: Fourteen to sixteen week size mobile uterus. Is it correct to have spelled out the numbers since it begins the sentence? ...

Unsure how to correctly type the 2+ 4. Does she mean 2+/4?? Thanks for helping. ...

Thanks so much!! ...

CHIEF COMPLAINT: Dyspnea. Then Dr. starts rattling the following off really quickly... For details on his (??personal??) past medical history please see dictates from p physical exam On admission please see dictates from p laboratory, please see dictates (H & P) . Does p stand for past or previous? Does this sentence look correct? Thx in advance. ...

Capitalize headings under Physical Exam? - I see both in samples

What does your client want? - Xena

Similar Messages: